The Care Quality Commission
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  • GP practice

Archived: Aelfgar Surgery

Overall: Good read more about inspection ratings

Church Street, Rugeley, Staffordshire, WS15 2AB (01889) 579276

Provided and run by:
Aelfgar Surgery

Important: The provider of this service changed. See new profile

All Inspections

4 November 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Aelfgar Surgery on 4 November 2019 due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: Safe, Effective and Well-Led. Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about services and
  • Information from the provider, patients, the public and other organisations.

We previously carried out a comprehensive inspection at Aelfgar Surgery on 8 April 2014. The overall rating was Good. The report on the April 2014 inspection can be found by selecting the ‘all reports’ link for Aelfgar Surgery on our website at .

We have rated this practice as good overall and good for the population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs and was planned and delivered according to evidence-based guidelines.
  • The practice understood the needs of its population and tailored services in response to those needs.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment and worked together and with other organisations to deliver effective care and treatment.
  • Audits demonstrated quality improvement.
  • Patients were treated with compassion, dignity and respect and were involved in their care and any decisions about their treatment.
  • Staff felt valued and supported by the leadership team.
  • Leaders understood the strengths and challenges of the services provided.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice had met the seven good practice recommnedations we previously made in relation to providing safe, responsive and well-led services.

The areas where the provider should make improvements are:

  • Formalise clinical supervision arrangements for staff employed in enhanced roles.
  • Review the security arrangements to ensure the safe storage of all emergency medicines and vaccines held at the practice.
  • Continue to review and improve the uptake of cervical cytology screening.
  • Ensure the required statutory notifications are submitted to CQC.
  • Develop a succession plan and share the mission statement with staff and patients.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of General Practice

8 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this service on 8 April 2015 as part of our new comprehensive inspection programme.

The overall rating for this service is good. We found the practice to be good in the safe, effective, caring, responsive and well-led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The majority of patients told us they were able to book appointments when required. However, other patients told us it was difficult to contact the practice by telephone, and often when they got through, all of the same day appointments had been taken.
  • The practice offered a range of in house services for patients, for example ultrasounds, community hearing care services and psychological therapies.
  • There were inter-practice arrangements in place to provide services to patients registered with other GP practices in the locality.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure all required recruitment checks are undertaken and kept in the relevant staff file.
  • Clarify the safeguarding leads within the practice and ensure all staff are made aware.
  • Ensure a system is in place to check the professional registration of the clinical staff is in date to ensure they are fit to practice.
  • Introduce a system for identifying, responding to, managing and reviewing risks to patients and the service.
  • Introduce a system to record and review all complaints.
  • Review the access to and availability of appointments.
  • Ensure policies and procedures are regularly reviewed and updated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice